Piriformis Syndrome

What is Piriformis Syndrome?

Piriformis syndrome is the term given to the effect caused by the Piriformis muscle on the sciatic nerve. The Piriformis muscle tracks from the anterior aspect of the middle of the sacrum, connecting with the sacrotuberous ligament, and running through the greater sciatic notch to attach to the superior aspect of the greater trochanter of the femur.

When the hip is flexed the Piriformis is a hip abductor. However, in conjunction with Gemellus Superior, Obturatus Internus, Gemellus Inferior, Obturator Externus and Quadratus Femoris, the Piriformis muscle is responsible for laterally rotating the femur whilst the hip is in extension. Together they are often termed ‘The Deep Six’. The Piriformis is therefore important in stabilising the hip joint and pelvis and maintaining healthy alignment of the trunk during ambulation.

The orientation of the Piriformis muscle and the sciatic nerve (as illustrated above) owes to potential problems. If the Piriformis irritates or compresses the proximal sciatic nerve causing inflammation then the client can experience:

• Pain in and around the hip joint and outside of the femur (greater trochanter)
• Pain in the centre of the buttock and potentially referred down the leg along the line of the sciatic nerve
• Tingling and numbness along the line of the sciatic nerve

These symptoms are also commonly associated with lumbar derangement and/or dysfunction. Differential diagnosis by a suitably qualified practitioner, taking into consideration the causative factors, would be required prior to diagnosing the client with Piriformis Syndrome.

In approximately 20% - 30% of the population research shows that the Piriformis muscle can be split by 1 or several parts of the sciatic nerve. So rather than traversing around the muscle, running alongside, it can actually pass through it. This population are obviously at higher risk of Piriformis syndrome as any imbalance of the muscle’s activity can lead to nerve entrapment.

What causes Piriformis Syndrome?

There are several causes of Piriformis Syndrome including:

• Anatomical anomalies (as outlined above)
• Direct impact trauma to the muscle itself causing fibrosis (falling on your bum!)
• Lumbar derangement and/or dysfunction causing reduced piriformis innervation from its nerve branches at L5, S1 & S2 leading to secondary hyper- or hypotrophy
• Hyperlordotic postures
• Prolonged standing postures
• Sports involving a repeatedly flexed trunk position (bowling, speed skating, cycling, etc)
• Overactive hip flexors
• Overpronation of the subtalar joint of the foot
• Muscle imbalance – Weak abductors vs. Overactive adductors

The majority of these are related to altered biomechanics sustained over a long period of time. This could be secondary to another imbalance / pathology. In order to correctly manage Piriformis Syndrome, the underlying cause MUST be addressed and not just the symptoms that the client presents with.

What is the management of Piriformis Syndrome?

Conservative treatment is the method of choice and can include:

• Correcting the underlying biomechanical cause
• Re-balancing the associated muscle tissue and
• Manual therapy
• Electrotherapy
• Acupuncture
• SPECIFIC STRETCHING / STRENGTHENING PROGRAMME*

Very rarely will treatment involve anything more invasive, but if so required, the client may need a cortisone injection or surgical intervention.

How can Pilates help with Piriformis Syndrome?

Considering the majority of clients diagnosed with Piriformis Syndrome have acquired it secondary to altered mechanics in the lumbar spine, pelvis or lower limb, Pilates is perfect for helping to alleviate their symptoms.

Aim to identify the causative factors IF the referring colleague has not already identified them for you. Most importantly, check the client’s lumbar, pelvic and lower limb alignment paying particular attention to their posture and foot to hip position. Consider whether they are restricted through movement of their lumbar spine, pelvis and/or hips.

A good place to start would be to observe their control of leg alignment during a basic leg slide:

• What happens to the angle of the hip?
• Does their leg rotate externally as they extend?
• Does their pelvis tilt/drop as they extend?

Obviously this will NOT conclusively give you a diagnosis of Piriformis Syndrome BUT correcting any of this misalignment can help with its management. Consider balancing out the pelvis. Specific stretches to release the Piriformis are available in abundance online and in decent texts, my personal favourite is the ‘Pigeon Pose’ in Yoga but this would usually be TOO hard for the client to start with. Simply sitting cross-legged for several minutes a day can help to release the tension in the Piriformis.

Releasing the Piriformis with or without the assistance of manual treatment from a suitably qualified practitioner should eventually result in the reduction of symptoms. Following which, you must aim to restore its functional strength, using specific exercises into external rotation and abduction at the right time, whilst maintaining healthy pelvic and spinal alignment.

As Pilates teachers, we have a wealth of knowledge on suitable exercises, however, the skill is to select the most effective for that individual. Try to relate it back to their causative factors maybe even combining it with helpful corrective lifestyle ‘cues’. Remember that something as simple as asking someone to just think about how they sit, walk or run, could have a resounding effect on their symptoms.